BOOK REVIEWS Chasing Polio in Pakistan: Why the World’s Largest Public Health Initiative May Fail. Svea Closser, Nashville: Vanderbilt University Press, 2010; 232 pp. Elisha P. Renne University of Michigan In Chasing Polio in Pakistan, Svea Closser provides an astute analysis of the Global Polio Eradication Initiative (GPEI) in one of three countries where wild poliovirus transmission has not yet been interrupted (Afghanistan and Nigeria are the other two). With a background in medical anthropology and public health, Closser was well positioned to carry out this multi-sited research, which she discusses in seven chapters, intersected by five short ethnographic interludes. Through her fieldwork, which included work with a district polio eradication team in Pakistan as well as interviews with WHO officials in Geneva and CDC officers in Atlanta, Closser has made an invaluable contribution to understanding the dynamics of a global health campaign. In Kaifabad, the pseudonym for the district and city where she served as an inadvertent health consultant monitoring immunization coverage, she worked with district health department officials, women vaccinators DOI: 10.1111/maq.12045 (referred to as “lady health workers” in Pakistan), intermediate and zonal supervisors, and drivers. Her detailed accounts of their endeavors to find unvaccinated children and give them doses of oral polio vaccine capture the full gamut of social life, with some individuals dedicated to the goals of the campaign, while others maneuvered to minimize their efforts. These narratives, along with her descriptions of the difficult ethical decisions she had to make regarding how to report missed children, provide some of the best ethnographic depictions of a public health campaign to date. Closser argues that the ambivalence and resistance of some health workers toward the polio eradication program— expressed by foot-dragging, data falsification, and reliance on patron–client relations that undermined WHO, UNICEF, and CDC personnel’s efforts—reflect resentment toward structures of inequality rather than suspicions about the vaccine itself, as was the case in Nigeria. Closser astutely observes that this inequality both perpetuates disease transmission and weakens efforts to implement health and disease control programs (11). She argues that global health leaders and major polio program funders, who failed to take political concerns and power hierarchies into account, have contributed to the Book Reviews situation of ongoing wild poliovirus transmission in Pakistan. The difficulties of this situation is compounded by what Closser refers to as a “culture of optimism,” exemplified by public pronouncements of GPEI officials and program funders, namely that polio eradication is “just around the corner,” that the technical means are there, and that polio eradication is simply a matter of political will that can be easily mustered. Despite these flights of fantasy—that political action can decreed from above and that the technical measures can overcome all obstacles, Closser, is, as she puts it, “unable to abandon polio eradication,” both because of the dangers of a resurgence of polio cases and because of the extraordinary efforts that many involved in the Initiative have made (178). Indeed, she argues that anthropologists have much to contribute to such global health programs, particularly in the planning stages when accounting for the feasibility of political support in the face of unequal power relations should be openly evaluated. This recommendation stems from her belief that medical anthropologists who critique health initiatives also have a responsibility to engage in constructive involvement. In this case, she suggests that anthropologists could contribute to planning for alternative, locally specific, strategies based on partnerships between international and community-based NGOs that would balance program goals with local needs and concerns. At the book’s end, she proposes one possible alternative approach for ending wild poliovirus transmission in Pakistan that would shift responsibility in problem districts to NGOs—she suggests Rotary International, USAID, organizations associated with Saudi Arabia, or national religious groups. Such groups would have the flexibility to run immunization campaigns, working closely with local communities leaders, while WHO personnel would continue to manage case surveillance (191). Although Closser is not entirely sanguine about the possibility for making such changes so late in the implementation of the GPEI, such a revised approach might have been possible if back-up plans had been formulated earlier on in the program. Closser also considers the policy of eradication, which has been much debated in public health circles. From her experience in Pakistan, she concludes that eradication is a useful public health strategy, particularly in areas with poor health care services. In such cases, programs such as the GPEI provide a modicum of health care. Yet, because of their narrow focus on one disease and not on other health problems, eradication programs contribute to the very global inequalities that have hampered the program’s progress in Pakistan. (One might also argue that this single-minded focus contributes to the culture of optimism that Closser rightly criticizes.) Part of the problem with concluding the polio campaign in Pakistan has been that government officials, facing many pressing problems, did not view polio eradication as a high priority. Recent events in Pakistan—the discovery of Osama bin Laden’s whereabouts in Abbottabad and the sequent trial and conviction of the Pakistani doctor who aided the CIA by Medical Anthropology Quarterly setting up a hepatitis B vaccination scheme there—underscores the complexity of politics and global health. In Chasing Polio, Closser makes an excellent contribution to our understanding of this complexity. The book’s content, as well as its organization and clear writing style, make it a useful addition to courses pertaining to global health and public health initiatives.
© Copyright 2024 ExpyDoc
